IOSR Journal of Dental and Medical Sciences (IOSR-JDMS)

e-ISSN: 2279-0853, p-ISSN: 2279-0861. Volume 11, Issue 2 (Nov.- Dec. 2013), PP 51-54
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From Veneers to Thineers: Two Case Reports with three years

follow up.
Dr. Panna Mangat1, Dr. Rajesh Podar2, Dr. Anjali Miglani3
(Conservative Dentistry and Endodontics, DJ College of Dental Sciences and Research, India) 1, 3
(Conservative Dentistry and Endodontics, Terna Dental college, India) 2

Abstract: This article presents two cases of aesthetic rehabilitation Case 1) Discoloured anterior teeth
(tetracycline staining) and Case 2) Diastema closure using minimal intervention dentistry by use of no
preparation or minimally preparation teeth. In this Case report porcelain thineers are fabricated which
provides best aesthetics with minimal preparation. The key learning points of the article are the following:
Proper diagnosis, treatment plan and proper execution of the treatment plan are mandatory for a successful and
pleasing result.
Keywords: Aesthetic Rehabilitation, Adhesive Technology, Minimal Invasive Dentistry, Thineers, Treatment
Planning

I. Introduction
While the treatment objectives of today’s dentistry regarding the restoration of form and function are
unchanged, the demands on quality and esthetics by the patient have grown. 1,2 Modern material and adhesive
techniques have innovated dentistry towards restoration which are truly invisible to the patient.3,4 With the
improvement of ceramic material and luting composites ceramics and successfully bonded to teeth,
conceptualising towards Minimally Invasive Dentistry.5,6 Porcelain thinners offer a predictable and successful
treatment modality in prosthetic dentistry. The aim of a veneer preparation is to avoid extensive tooth
preparation and provide reinforcement of residual tooth structure. Quality of esthetics achieved with bonded
restoration is considered a state of Art. Following the facial veneer preparation the increase in flexure can
amount to 91%as measured by 3D FEA. 7 Bonded ceramic veneers are capable of restorting the fracture strength
of teeth to values of intact teeth. 4, 8, 9, 10 Porcelain veneers are perceived to be one of the most conservative
means of restoring aesthetic anterior teeth. Their indications include discoloration, tetracycline staining, flurosis,
diastema closure, malformed and malpositioned teeth.11, 12, 13
Purpose of the clinical report is to emphasise on conservative method of aesthetic rehabilitation thus
preserving the vitality of the teeth.

II. Case Report:

Case I:- A 40yr old male patient reported with chief complaint of discoloured (tetracycline stained)
anterior teeth.
Case report 2: A 31 year old patient reported with chief complaint of spacing between upper anterior
teeth.
A comprehensive examination was conducted including caries detection, periodontal probing, intraoral
and extraoral soft tissue and TMJ examination. Findings were within normal limits and therefore were
considered non-contributory. The masticatory and cervical muscles were palpated. Determination was made that
occlusion was physiologic and that the patient should be restored to a position of MID.
Following a detailed clinical examination the objective parameters of the patient’s smile were carefully
evaluated. Intra and extraoral photographs were taken in order to aid in the aesthetic evaluation. Study models
were obtained with Reprosil (Dentsply/ Caulk, Milford, DE,USA).
Ceramic thineers were best suited for the condition. These thineers have the advantage of preserving
most of the natural tooth structure while achieving all the cosmetic aids. These can be prepared as thin as
0.3mm. Prior to beginning preparation of the teeth, the color of ceramic thineers was chosen and incisal
guidance was checked. All the essential information required to successfully complete the restorative care was
gained at the preliminary stage, prior to fabrication of the definitive restoration.
Diagnostic casts were mounted in an articulator, and a preliminary diagnostic wax-up was done. The
potential aesthetic benefits of the recommended treatment were demonstrated to the patient using a putty stent
obtained from the wax-up of the proposed treatment.

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 From Veneers to Thineers: Two Case Reports with three years follow up.

2.1 Preparation
Case 1- Only a minor reduction of the incisal one third (1mm) of the lower anteriors was done to create an
incisal stop.

Case 2- No preparation.
Polyvinyl siloxane final impressions (Imprint II, 3M Dental Products) were made of the prepared teeth, and
master casts were fabricated. The master casts were cross-mounted with the casts of the wax-up using centric
relation interocclusal records permitting efficient attainment of correct tooth length, positioning of the midline,
duplication of crown contours, and orientation of the occlusal plane. Fit, natural appearance, translucency and
the absence of the black triangle in the gingival area were checked.
All of these parameters had been previously determined in the wax up and had been accepted by both the
patient and the dentist. The definitive restorations were fabricated and cemented.

2.2 Thineer manufacture:

According to manufacturer’s instructions, IPS- E max thineers were fabricated. (IPS Emax, Ivoclar
Vivadent).

2.3 Luting procedure:

Rubber dam and retraction cord was placed to prevent gingival fluids from contaminating the teeth
during bonding process.

Before bonding, both surfaces had to be conditioned. Conditioning of ceramic consisted of degreasing
with acetone, etching with Hydrofluoric acid (Vita ceramic etch, Vita Zahnfabrik; Bad Sackingen,Germany) for
30seconds, rinsing for 60 seconds and applying Silane (Monobond-S Ivoclar Vivadent) for 60 seconds.
Teeth were conditioned according to the following protocol. After cleaning and polishing with brushes
and polishing paste, the enamel was etched with 37% phosphoric acid (Total Etch, Ivoclar Vivadent) 30 seconds
and for dentin 15 seconds.
After thoroughly rinsing and drying the dentin was rewetted with a moist Appli tip (SDI Cari-Tip,
Vasbi, Sweden). Syntac primer (Ivoclar Vivadent ) and adhesive was applied for 15 seconds and dried with a
gentle blast of air followed by Syntac adhesive (Ivoclar-vivadent) according to manufacturer’s instructions.
After evaporation of the solvent, Heliobond Resin(Ivoclar-vivadent) was applied in thin layer.
The thineers were bonded with high viscosity dual polymerizing resin composite (Variolink II, Base:
Catalyst, translucent shade, Ivoclar Vivadent). Base and catalyst were mixed in a ratio 1:1 ratio and applied to
inner surface of the restoration. The thineers were luted using an ultrasonic device (Master Piezon 400,
EMS;Nyon, Switzerland) with a modified rubber tip (SP-Tip, EMS). After seating the veneers with luting
cement on the preparation excess luting resin was removed with a brush and before light curing the resin
composite the veneer margin was covered with glycerine gel (Liquid Strip; Ivoclar Vivadent) to prevent oxygen
inhibition layer. Luting interface was light polymerized (Spectrum 800, Dentsply De Trey; Konstanz, Germany)
from facial, palatal, mesial and distal interproximal aspects for 60 seconds each, resulting in total
polymerization time of 240 seconds. After setting, floss was gently placed into the interproximal areas to
remove uncured resin. The margins were finished with finishing diamonds (Gebr. Brasseler) and aluminium
oxide polishing disks (Sof Lex 3M; Broken, Germany).
Patient was recalled for routine check up every six months over a period of three years for marginal
integrity, aesthetic, oral hygiene maintenance, durability of the restoration, for any visible cracks, debonding,
discoloration, gingival inflammation. At the end of three years follow up the clinical outcome was aesthetically
pleasing and immaculate.

Case 1- Teteracycline Staining

Pre-operative Post-operative

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 From Veneers to Thineers: Two Case Reports with three years follow up.

Lateral View right Lateral View left

Post-Operative Three Years

Case 2 – Diastema Closure

Pre –operative Post-operative

Pre-operative Intraoral Post-operative Intraoral

Post Operative Three years Wax Up

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 From Veneers to Thineers: Two Case Reports with three years follow up.

III. Discussion
It is the responsibility of the clinician to fully understand the limitations of the veneers in masking the
severe discolorations, taking in tot account that each Ceramic system is unique to its optical properties.
This will ultimately affect the final esthetics of the restoration, the type of ceramic needs to be chosen according
to each clinical situation.
Bonded ceramic veneers have a number of significant advantages over metal ceramic / all ceramic
crowns. One of the most important advantage is that they are extremely conservative in terms of tooth structure.
The most common complications for crown in general are loss of pulp vitality and fracture of the core.
Comparing the volume of tooth structure removed for an all-ceramic crown preparation to a veneer preparation,
double the amount of tooth structure is removed for a crown than a veneer. 14
Conservation of the tooth structure is a major factor in determining the long term prognosis of any
restorative procedure. Another advantage of the ceramic veneers is their durability. This durability allows
minimal reduction resulting in reduced potential pulpal involvement. The periodontal response is beautiful. The
restoration can blend imperceptibly with the cervical tooth structure, allowing the cervical margins to be kept in
supragingival position.15
Theses ceramic veneers should be placed in enamel however with contemporary dentin bonding
systems margins can be successfully placed on the dentin/cementum when necessary.
The combination of hydrofluoric acid etching with a silane coupling agent seems to be superior for conditioning
the intaglio surfaces of the glass ceramic laminate veneers in comparison to other methods.16, 17, 18
It was even demonstrated that adhesion of resin cements on hydrofluoric acid etched and silanized
ceramic had higher bond strength than the same luting cement bonded to enamel.19 This combination is stable
after long term water strength and thermocycling. 16, 17, 18 Process of silanization promotes the wettability on the
ceramic and composite surfaces and reacts with the silica surfaces to form covalent bonds. 16
The success of treatment with ceramic veneers can be assured if the dentist follows a defined protocol
with each patient to ensure that all factors such as smile design, margin placement, material and shade selection
are considered.

IV. Conclusion
Aesthetic assessment prior to initiating treatment is critical to achieving the best outcome. Proper
guidance in protrusive and lateral excursions must be established to ensure longevity of the restoration.
Selection of the best materials to achieve these parameter is of utmost importance. A systematic approach leads
to more predictable outcome.

References
[1]. Heinlein WD. Anterior teeth: esthetics and function. Journal of Prosthetic Dentistry 44, 1980,389-393.
[2]. Mc Lean JW. Aesthetics in restorative dentistry: the challenge for the future. British Dental Joural 149, 1980,368-374.
[3]. Magne P, Douglas WH. Rationalization of esthetic restorative dentistry based on biomimetics. Journal of Esthetic Dentistry 11, 1999, 5-15.
[4]. Magne P, Besler U. Bonded porcelain restorations in the anterior dentition: A biometric approach. Chicago: Quintessenc 2002.
[5]. Simonsen RJ. The preventive resin restoration: a minimally invasive, non metallic restoration. Compendium 8,1987, 428-432.
[6]. Tyas MJ, Anusavice KJ, Frencken JE, Mount GJ. Minimal intervention dentistry, a review. FDI Commision Project 1-97. International
Dental Journal 50, 2000, 1-12.
[7]. Magne P, Tan DT. Incisor compliance following operative procedure: A rapid 3-D finite element analysis using micro CT data. Journal of
Adhesive Dentistry 10, 2008, 49-56.
[8]. Andreasen FM, Flugge E, Daugaard Jensen, Munskgaard EC. Treatment of crown fractured incisors with laminate veneer restorations. An
experimental study. Endod Dental Traumatology; 8, 1992, 20-35.
[9]. Magne P, Douglas WH. Design optimization and evolution of bonded ceramics for the anterior dentition. A finite element analysis.
Quintessence International. 30, 1999, 661-672.
[10]. Stappert CF, Ozden U, Gerds T, Sturb J.R.Longevity and failure load of ceramic veneers with different preparation designs after exposure to
masticatory simulation. Journal of Prosthetic Dentistry 94, 2005, 132-139.
[11]. Weinstein A esthetic appliance of restorative materials and techniques in the anterior dentition. Dental Clinics of North America 37(3),
1993,391-409.
[12]. Lim C. Case selection for porcelain veneers. Quintessence International 26(5),1995, 311-315.
[13]. Peumans M, Van Meerbeek B, Lambrechts P, Vanherle G. Porcelain veneers: A review of the literature. Journal of Dentistry 28(3), 2000,
163-177.
[14]. Edelhoff D, Sorensen JA. Tooth structure removal associated with various preparation designs for anterior teeth. Journal of Prosthetic
Dentistry 87, 2002,503-509.
[15]. Shailendra Gupta, Deepak Raisingani, Pradyumna Misra. Esthetic rehabilitation with ceramic veneers: A Case Report. International Journal
of Contemporary Dentistry; 2(1), 2011, 13-16.
[16]. Blatz MB, Sadan A, Kern M. Resin- ceramic bonding: a review of the literature. Journal of Prosthetic Dentistry 3, 2003, 268-274.
[17]. Bltaz MB, Sadan A, Maltezos C, BLatz U, Mercante D, Burgess JO. In vitro durability of the resin bond to feldspathic ceramics. American
Journal of Dentistry 17, 2004,169-172.
[18]. Brentel AS, Ozcan M, Valandro LF, Alarca LG, Amarai R, Bottino MA Microtensile bond strength of a resin cement to feldspatic ceramic
after different etching and silanization regimens in dry and aged conditions. Dental Materials 23, 2007, 1323-1331.
[19]. Penumans M, Meerbeek van B, Lambrechts P, Vanherle G. Porcelain veneers: a review of the literature. Journal of Dentistry 28, 2000, 163-
177.

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